ACA repeal could threaten treatment for addiction, mental health

More than 272,000 Texans could lose access to mental health and substance abuse treatment if one of the lesser known guarantees of the Affordable Care Act goes away with the law’s repeal and is not replaced.

This article originally appeared in the Houston Chronicle on February 15, 2017

In Texas alone, 65,559 people with the most serious types of debilitating mental illnesses, such as bipolar disorder or schizophrenia, are now covered by individual plans offered under the health care law, according to a data analysis released this week by the Harvard Medical School and New York University.

Another 53,539 receive coverage for less serious mental health conditions, while 152,971 Texans have gained coverage for treatment of substance abuse, including alcoholism and opiate addiction, the study shows.

Nationally 4 million people with a serious mental health illness or who struggle with substance abuse could lose some or all of their coverage, according to the findings.

Under the current law, behavioral health coverage is required in individual and small group plans under a provision known as the “essential health benefits.” It remains unknown if such a guarantee will survive in the yet-to-be-unveiled Republican replacement plan for the law known as Obamacare.

U.S. Rep. Kevin Brady, R-The Woodlands, is among House Republicans leading the charge to repeal the law and replace it with a more streamlined version. He did not respond directly to an emailed question Wednesday about whether the replacement plans being discussed include comparable coverage for mental health and substance abuse treatment.

Instead, he replied in a statement that “we’re focused on reforms that will encourage innovation and competition – so there are more health care options to meet the unique needs of different individuals and families.”

Richard Frank, a Harvard Medical School health economics professor and co-author of the study out this week, worried that removing the requirement for insurers would hit an especially vulnerable population hard.

“We don’t want to make access harder, we want to make it easier,” Frank said in an interview. “These are things that should be worrying us.”

They certainly worry Alice Brink. Before the ACA, the 63-year-old Houston communications consultant was unable to get mental health coverage as part of her health plan because insurers discovered she had been seeing a therapist to help manage stress.

She was not on medication and did not have a specific diagnosis of a mental illness. But the visits alone were enough to trigger the red flag of pre-existing condition and a denial.

Coverage limited

Brink, who has two years until she is eligible for Medicare, said she is more fearful for her two adult sons. They have both been treated for mental health conditions in the past and one also for substance abuse. That pairing is not unusual as people with mental illness often turn to alcohol or drugs to self-medicate. Before the ACA, one son was uninsured and the other had coverage only occasionally.

Brink worries that without guaranteed coverage, both will be considered uninsurable. In the past, without insurance, they paid out of pocket for treatment. Sometimes they skipped medication or doctor visits when money got tight. The treatment gaps only worsened their conditions.

“All three of us have policies on the exchange,” she said. “It terrifies me that my sons in their 30s could have to go for the next 30 years without insurance unless they get the kind of corporate jobs that will give them coverage.”

Both the Republican-led Congress and President Donald Trump have called the ACA a “disaster” and an untenable financial burden on Americans.

Last month the House and Senate began the framework to quickly gut the law. Trump, within hours of being inaugurated, signed a sweeping executive order directing federal agencies to lift or ignore its regulations, presumably taking aim at some of the mandates.

That could include the essential health benefits.

The Washington Post has reported the new Trump administration is considering allowing insurance companies to strip down or eliminate some of the essential health benefits as a way to cut costs.

Typically, large group and employer-sponsored health plans offer mental health and substance abuse coverage, although its breadth can vary.

Frank, who worked for the U.S. Health and Human Services during the Obama administration helping to develop strategies to combat opiate addiction, said he is especially concerned about the lack of specifics in Republican replacement plans.

“I’ve not seen anything in the repeal and replace discussion that indicates (mental health and substance abuse coverage) will be preserved,” he said.

Just looking at what it was like before the mandated coverage offers a glimpse of what is at stake:

In Texas, for instance, one in three individual insurance plans did not include addiction treatment. Between 15 and 20 percent of individual plans did not include mental health coverage, Frank said.

Then there were the uninsured. Before the ACA, about 26 percent of Texans were without coverage. Even today, the state still leads the nation with about 4.6 million residents who do not have coverage.

Frustrations mount

Frank added that before mandated coverage, the mental health and substance abuse coverage in Texas was often skimpy, allowing only 20 visits per year and putting a tight limit on in-patient care.

“That meant if you were really sick, even if you had insurance, you were at risk for a very large financial hit,” he said.

Greg Hansch, public policy director for the National Alliance on Mental Illness Texas, said going backward would not only erase the progress but also could create hardships on entire communities.

“It would mean a lot more people ending up in the ERs and jails if they don’t have coverage on the front end,” he said.

During the presidential campaign, Trump promised to address the opiate epidemic and expand access to drug treatment. He won in many of the states staggering under the crisis, including Kentucky, Ohio and West Virginia. But those states also expanded Medicaid, under the ACA, which helped provide funding for treatment.

Funding for Medicaid expansion could also fall under dismantlement plans. Thirty-one states expanded Medicaid. Texas is one of 19 that did not.

Late last year, with strong bipartisan support, Congress passed the 21st Century Cures Act that includes a host of health-related initiatives including $1 billion to expand drug treatment. Money will be allocated to states, especially those with the highest needs.

Still, some behavioral health advocates worry that will not be enough and programs could become out of reach if people lose insurance coverage or it becomes too limited.

For people like Brink, who has fought hard for mental health coverage for herself and her family, the politics are frustrating.

“It’s like watching a soufflé that you put together so carefully,” she said, “and then someone comes along and slams the oven door shut.”